D. M. Ferguson1,2, K. T. Anderson1,2, M. A. Bartz-Kurycki1,2, K. Tsao1,2 1McGovern Medical School at UTHealth,Department Of Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Department Of Pediatric Surgery,Houston, TX, USA
Introduction: Despite common use, few data exist regarding the efficacy of intraoperative drain placement for preventing post-operative intra-abdominal abscesses (IAA) in perforated appendicitis. Our aim was to evaluate the efficacy of intraoperative drain placement in pediatric perforated appendicitis patients.
Methods: We performed a retrospective review of a prospective cohort secondary to a quality improvement project. In an effort to reduce IAAs, closed suction drains were placed intraoperatively in pediatric (age <18) perforated appendicitis patients from 2013-2016. These patients were compared to pre- and post-intervention controls from 2013 and 2016. Perforated appendicitis was defined as visualization of a hole in the appendix or intra-abdominal stool. All patients received protocolized pre- and post-operative care, including initiation of intravenous antibiotics at diagnosis and continuation until discharge, preoperative prophylactic antibiotics, standardized discharge criteria and 7 days of oral antibiotics after discharge. Intraoperatively discovered abscesses were managed by suctioning without irrigation. Drain placement was standardized with 2 drains per patient. The primary outcome was a composite of any complication. Secondary outcomes included post-operative IAA, emergency visit, readmission, superficial surgical site infection (SSI), small bowel obstruction (SBO), post-operative computed tomography (CT), post-operative percutaneous drain or aspiration, and length of stay (LOS). Descriptive statistics, chi2, student’s t-test and logistic regression with purposeful selection (p<0.20) were used for analysis.
Results: Patients with drains (n=261) were similar to those without drains (n=291) by gender, race/ethnicity, insurance status, admission white blood cell count, and symptom duration prior to arrival. The drain cohort was significantly younger (mean 9.4±4.0 vs 10.6±4.2 years, p<0.01) and weighed less (mean 40.4±22.2 kg vs 46.0±26.1 kg, p<0.01). The rate of post-operative IAA was not significantly different between the groups. Patients with drains had longer LOS (drain: mean 6.5 days±4.1 vs. no drain: 5.3 days±3.6, p<0.01), more frequent post-operative CT use, and an increased proportion of small bowel obstruction (OR 4.90; 95%CI 1.06-22.71). Adjusting for age did not reduce the proportion of post-operative IAA in patients with drains (OR 1.03, 95% CI 0.97-1.08).
Conclusion: Intraoperative drain placement does not reduce the rate of postoperative IAA in pediatric perforated appendicitis and is associated with increased LOS, imaging, and SBO. Without evidence of benefit, and in light of the suggestion of harm, we do not recommend routine drain placement.
